Accountable Communities for Health Opportunities and Recommendations Executive Summary

ACCOUNTABLE COMMUNITIES FOR HEALTH: OPPORTUNITIES AND RECOMMENDATIONS Executive Summary July 2015 PREPARED FOR THE STATE OF VERMONT DEPARTMENT OF VERMONT HEALTH ACCESS... EXECUTIVE SU

ACCOUNTABLE COMMUNITIES FOR HEALTH:

OPPORTUNITIES AND RECOMMENDATIONS

Executive Summary

July 2015

PREPARED FOR THE STATE OF VERMONT DEPARTMENT OF VERMONT HEALTH ACCESS

EXECUTIVE SUMMARY

INTRODUCTION

he Accountable Community for

Health (ACH) model is emerging as a

promising vehicle toward reaching

the full potential of the Triple Aim—

particularly efforts to improve population

health Catalyzed by the Affordable Care

Act, the U.S health system is in the midst of

an unprecedented period of transformation

Communities and states across the country

are embracing a wave of innovation and

experimentation to achieve the Triple Aim

of reduced cost, enhanced quality of care,

and improved population health The third

aim–improving population health–stands out

as a more recent area of focus, and thus

opportunity, for healthcare leaders to

expand the scope of their work

This report presents research and analysis

conducted by Prevention Institute under

contract with the Department of Vermont

Health Access to inform the potential

development and application of the ACH

model within Vermont’s healthcare

landscape The work was carried out in

close collaboration with the Population

Health Work Group and Vermont Health

Care Innovation Project leadership

Prevention and Population Health

Improvement

Population health is commonly defined as

“the health outcomes of a group of

individuals, including the distribution of such

outcomes within the group.” Further,

“population health outcomes are the

product of multiple determinants of health,

leaders embrace the notion of population health, they increasingly recognize that factors outside the healthcare system have a powerful impact on health The analysis that access and quality of care only accounts for 10% of the factors contributing to health outcomes1 is now a core principle underlying health system transformation efforts

Quality community prevention is aimed at

addressing the social, economic, and physical environment that is shaping population health outcomes It involves a spectrum of comprehensive and synergistic activities that range from increasing individual skills and knowledge (motivational counseling to quit smoking) to changing organizational practices (establishing a tobacco-free workplace) and policies (tobacco-free parks and public spaces)

Another benefit of community prevention is its applicability to improving mental health

in addition to physical health Community prevention serves as a strong complement

to clinical care and service referral, decreasing the future patient pool while also helping those already sick or injured recuperate and maintain their health

T

“No mass disorder afflicting mankind is ever been brought under control or eliminated by attempts at treating the affected individual.”

- Dr George W Albee, Former Professor,

University of Vermont

The Accountable Community for Health Model

The Vermont Population Health Work Group’s working definition of an ACH is:

An Accountable Community for Health advances previous efforts in community health by

engaging healthcare as a central partner in community-wide health improvement At its core,

the ACH is a structure for collaboration that represents a major change in direction in

healthcare with tremendous opportunities and challenges

As emerging, the ACH concept is unique in that it:

1) Brings together major healthcare providers across a

geographic area, and requires them to operate as partners

rather than competitors;

2) Focuses on the health of all residents in a geographic area

rather than just a patient panel;

3) Engages a broad set of partners outside of healthcare to

improve overall population health; and

4) Identifies multiple strands of resources that can be applied

to ACH-defined objectives that explore the potential for

redirecting savings from healthcare costs in order to sustain

collaborative efforts

“An aspirational model—accountable for the health and well-being of the entire

population in its defined geographic area and not limited to a defined group of

patients Population health outcomes are understood to be the product of

multiple determinants of health, including medical care, public health, genetics,

behaviors, social factors, economic circumstances and environmental factors An

ACH supports the integration of high-quality medical care, mental and behavioral

health services, and social services (governmental and non-governmental) for

those in need of care It also supports community-wide prevention efforts across

its defined geographic area to reduce disparities in the

distribution of health and wellness.”

Collaboration often reflects long-term relationships and a commitment to one’s hometown or region.*

METHODS

Prevention Institute conducted an extensive research process to determine the potential for

establishing ACHs in Vermont, working closely with the State of Vermont Population Health

Work Group This process involved identifying five national sites that were engaged in activities

that aligned with the concept of an ACH; conducting interviews with core team staff members

and affiliated partners that represented different sectors; and producing case studies for each

site The second half of the investigation focused on identifying existing efforts in Vermont that

could potentially form the basis of an ACH Using responses to an online request for

information, six Vermont communities were selected for review; findings were summarized in

brief profiles Additional information about the Vermont landscape was provided through

meetings with the Population Health Work Group and State of Vermont Health Care

Innovation Project and Department of Health staff Based on these sources, Prevention Institute

produced an analysis of core elements of an ACH and recommendations for potential

implementation of an ACH initiative

SYNTHESIS OF FINDINGS

Overarching themes were drawn from the research findings

Themes from the National Case Studies

 The Accountable Community for Health model is in

the developmental stage; no community has all the

envisioned elements in place

 Relatively few U.S communities are implementing

healthcare delivery and payment reforms that include

community prevention strategies as a key pillar for

improving population health

 The focus of advocacy and policy change in places

engaged in community prevention is most frequently

related to food, physical activity, and tobacco

 The social and economic needs of patients and

low-income community residents are broadly recognized

and primarily addressed through individual service

referrals

 Ongoing engagement of community residents in planning and implementation processes,

beyond the community health needs assessment, is a challenge

 Emerging ACHs are using a variety of financing mechanisms, including grants, local

government general funds, dedicated taxes, or a portion of Medicaid’s global budget

Decades of investments in community prevention to address chronic disease through policy, systems, and environmental changes aimed at addressing tobacco, food, and activity behaviors have had a significant impact.*

Themes from Vermont Sites

 Vermont’s hospital and health system leadership is interested in the ACH model

Notably, in contrast to the national case studies, hospitals are serving as the integrator

organization in the majority of Vermont sites

 Vermont collaboratives are focused on a similar set of priority community health

challenges as the national sites, including: chronic disease related to tobacco, food, and

activity behaviors; mental health and substance abuse; and poverty

 Strategies to address health priorities typically involved health education and referrals to

community services All the Vermont collaboratives

described at least a few local- and state-level policy

goals Three of the six communities have a more

developed approach to promoting a menu of

community environmental changes

 Vermont sites are clearly focused on improving

access to non-medical services (ranging from mental

health and substance abuse treatment to

governmental and non-governmental social and

economic support services) and coordinating them

with medical services The Vermont Blueprint for

Health Community Health Teams are integral to

this service coordination

 The paradigm differences between partners around the ACH table can influence priority

setting Healthcare and service providers by organizational mandate and professional

training may place greater emphasis on improving services to individual clients

Findings by Core Element

Prevention Institute identified nine core elements of the ACH model:

Community-wide prevention organizations apply an environmental lens

to identify community factors that can be improved to prevent illness and injury.*

Core Elements of an Accountable Community for Health

1 Mission

2 Multi-Sectoral Partnership

3 Integrator Organization

4 Governance

5 Data and Indicators

6 Strategy and Implementation

7 Community Member Engagement

8 Communications

9 Sustainable Financing

1 Mission – An effective ACH mission statement provides an organizing framework for the

work A strong mission defines the work as pertaining to the entire geographic population of

the ACH’s region; articulates the ACH’s role addressing the social, economic, and physical

environmental factors that shape health; and makes health equity an explicit aim

2 Multi-Sectoral Partnership – An ACH comprises a

structured, cross-sectoral alliance of healthcare, public health,

and other organizations that impact health in its region Partners

include the breadth of organizations that are able to help it fulfill

its charge of implementing comprehensive efforts to improve the

health of the entire population in its defined geographic area

3 Integrator Organization – To maximize the effectiveness of the multi-sectoral

partnership, it is essential for the ACH to have an integrator organization The integrator helps

carry the vision of the ACH; build trust among collaborative partners; convene meetings;

recruit new partners; shepherd the planning, implementation, and improvement efforts of

collaborative work; and build responsibility for many of these elements among collaborative

members

4 Governance – An ACH is managed through a governance structure that describes the

process for decision making and articulates the roles and responsibilities of the integrator

organization, the steering committee, and other collaborative partners

5 Data and Indicators – An ACH employs health data, sociodemographic data, and data on

community conditions related to health (such as affordable housing, food access, or walkability)

to inform community assessment and planning, and to measure progress over time It

encourages data sharing by partners to inform these activities Equally important, an ACH seeks

out the perspectives of residents, health and human service providers, and other partners to

augment and interpret quantitative data

6 Strategy and Implementation – An ACH is guided by an overarching strategic

framework and implementation plan that reflects its cross-sector approach to health

improvement and the commitment by its partners to support implementation The process for

developing this framework includes a prevention analysis that identifies community conditions

that are shaping illnesses and injuries across the community The implementation plan includes

specific commitments from healthcare, local government, business, and non-profit partners to

carry out elements of the plan

7 Community Member Engagement – Authentic community engagement is a

well-recognized best practice in the field of community health that requires commitment from the

highest levels, designated staff, and commensurate resources to ensure effective integration into

ACH processes and systems Authentic community engagement recognizes and harnesses

Trust was described

as the most critical attribute of an ACHs

coordinating organization.*

8 Communications – An ACH employs communications platforms to build momentum,

increase buy-in amongst its partners, recruit new members, and attract grant investment to

support its work, and share successes and challenges with others Communications is also a key

tool for framing solutions in terms of community environments and comprehensive strategies

9 Sustainable Financing – An ACH requires resources to support both its integrator

function and ACH implementation work by others An ACH makes use of existing and new

funding sources and better aligns them to advance broad community goals

STATEWIDE RECOMMENDATIONS Accountable Communities for Health in Vermont

Vermont has many building blocks in place that make the establishment of ACHs a logical next

step in advancing health reform efforts Vermont’s working definition of an ACH is notable in

that it specifically calls out two important pillars of a system of health:

 Integrated medical care, mental and behavioral and social services

 Community-wide prevention efforts

The following recommendations are offered for consideration to advance and nurture local

ACH efforts

A Foster an overarching statewide approach to support ACH effectiveness

Develop a statewide strategic framework for population health improvement to support

local ACHs in setting priorities The state framework should span service integration and

community prevention, and illustrate multiple influences on health Language that emphasizes

health equity should be elevated The State itself should reflect these priorities in its overall

approach to population health by directing funding to communities that have the most impacted

community environments, and by supporting and engaging community resident leaders

Establish a core set of community-level indicators for use by local ACHs to monitor

progress in community-wide prevention Ensure the indicators reflect the contribution of

multiple sectors to health There are Vermont resources to draw on for community indicators,

such as: Scorecards developed by Rise VT to promote healthy environments related to food,

activity, and tobacco; or the ECOS Scorecard, Chittenden County, which also includes

indicators related to community planning, transportation, and economic development

Emphasize accountability mechanisms that are linked to population health

improvement To achieve Vermont’s goals, it may be advantageous to tie accountability more

with achievement of process and outcome measures that fall along the pathway to improved

population health

Phase in the formation of ACHs Vermont’s healthcare innovations implemented in the

Blueprint Health Service Areas have set the stage for considering ACHs in all 14 places We

recommend beginning with providing funding to localities with greater readiness to test out the

ACH elements, then refining the model based on these experiences

Explore the role of the State Government Department of Health, and other regional

offices, in participating in local ACH collaboratives We recommend further assessment to

determine the opportunities and challenges to facilitating this participation, and what it would

take to equip staff to effectively participate

B Provide guidance to enable regions to effectively establish ACHs

Ensure ACHs balance individual service

integration and community prevention efforts

The State should require that localities receiving

funding for ACHs engage in a comprehensive set

of strategies that span service integration and

community prevention work

Conduct a network analysis of community

prevention efforts in each Health Service

Area Building on the Vermont Blueprint analysis

of healthcare and community service providers in

these regions, we recommend initiating a

complementary assessment of community efforts

related to prevention with an emphasis on factors

such as food systems, tobacco control, housing,

transportation, and environmental sustainability

Encourage ACHs to form around existing regional partnerships and collaborations Since

the most critical element of an ACH is effective partnership in a defined geographic area, it may

make sense to consider local variation if partners have a strong history of working together or

make a compelling case for varying from the Health Services Area Further, in order to

encourage well-functioning ACH partnerships, we recommend the State not designate a specific

type of organization to serve as the integrator

C Build capacity and create an environment of ongoing learning

Expand the paradigm of the health system from healthcare to health ACHs are

establishing a new leadership paradigm, in which healthcare is helping to drive community-wide

changes for population health improvement More broadly, effort is needed across the state to

“Preserving good health and preventing disease is so obviously important that few would disagree that they should be the focus of any health care system; yet prevention is frequently neglected to address the more immediate demand for care.”*

- Vermont Blueprint for Health:

2014 Annual Report, p 10.

innovation There is an emerging set of practices for hospitals and community clinics—beyond

their role in the ACH per se—to use their power as anchor institutions, as employers, as

purchasers, and as credible health leaders to support community environmental changes to

improve patient outcomes.”2,3,4

Foster skill development for the emerging cadre of ACH leaders The State will need to

facilitate assessment and delivery of training and technical assistance around the core ACH

elements, and foster peer learning It can also be an opportunity to expand knowledge about

core community prevention concepts and practices and their importance for population health

improvements—serving to inform and attract state leaders to contribute to building strong

local ACHs

Promote authentic community engagement in all aspects of the ACHs and their work

ACHs in Vermont should be explicitly required to engage community residents, with a

particular emphasis on involving individuals and populations whose voices are most commonly

missing from the table Authentic community engagement will support greater success in

population health improvement efforts

Encourage the creation of robust communications platforms for the ACHs Regional ACH

organizations will benefit from State support in developing and disseminating communications

materials

D Explore Sustainable Financing Models for Accountable Communities for Health

Funding is necessary for ACH effectiveness We recommend building up and aligning ACH

funding with existing prevention funding streams as well as exploring ways to create a new

funding mechanism Across the country new ideas and funding models are emerging

Potential options include:

 Dedicating a portion of a new or existing tax to fund ACH activities

 Specifying that a portion of a global healthcare payment or a per-patient per-month

assessment on payers support the ACH upstream effort

 Establishing a wellness trust to support the ACHs, funded through one or a blend of the

sources described previously under core element nine

* Quotes pulled from the Accountable Communities For Health: Opportunities and Recommendations

full report

2

Serang F, Thompson JP, Howard T The Anchor Mission: A Case Study of University Hospitals Vision 2010 Program University Hospitals,

Cleveland, OH 2013

3

Phillips FB Sustaining Community-Hospital Partnerships to Improve Population Health Maryland Community Health Resources Commission

2015

4

Cantor J, Cohen L, Mikkelsen L, Pañares R Community Centered Health Homes: Bridging the gap between health services and community

prevention Oakland, CA: Prevention Institute 2011.

ACKNOWLEDGEMENTS

Prevention Institute would like to thank the many individuals representing National and Vermont

sites who provided invaluable input via interviews that helped shape and refine our thinking

This report was written by Leslie Mikkelsen, MPH, RD and William L Haar, MPH, MSW with

contributions by Victoria Nichols and Larry Cohen Special support from the Prevention Institute

“Vermont Team,” Lisa Dulsky Watkins, MD, of Granite Shore Consulting, LLC and Kalahn

Taylor-Clarke, PhD, MPH of George Mason University Additional support from Prevention Institute staff

members: Maya Dougherty, Zack Kaldveer, Lauren Sharp, Sana Chehimi, Anna Realini, and Kinnari

Shah

Funding for this report was provided by the State of Vermont, Department of Vermont Health

Access, Vermont Health Care Innovation Project, under Vermont's State Innovation Model (SIM)

grant, awarded by the Center for Medicare and Medicaid Services (CMS) Innovation Center (CFDA

Number 93.624) Federal Grant #1G1CMS331181-03-01 Prevention Institute would like to extend

special thanks and gratitude to our program manager, Heidi Klein, Director, Division of Health

Surveillance at Vermont Department of Health for her guidance and steadfast support of this effort

Members of the State of Vermont Population Health Work Group Planning Team—Tracy Dolan,

Karen Hein, MD, Jim Hester, PhD, and Georgia Maheras, Esq.—are greatly appreciated for their

guidance and insightful reflections throughout the project

Prevention Institute would also like to thank our longstanding philanthropic partners: Blue Shield of

California Foundation, The California Endowment, and The Kresge Foundation, which helped to

make this effort possible

Suggested Citation

Mikkelsen L, Haar WL Accountable Communities for Health: Opportunities and Recommendations

Prevention Institute 2015

Cover Photo Credit: Kimberly Vardeman, creative commons

About Prevention Institute

Prevention Institute (PI) is a national nonprofit dedicated to improving community

health and equity through effective primary prevention: taking action to build resilience

and to prevent problems before they occur Our work is characterized by a strong

commitment to community participation and promotion of equitable health outcomes

To help shape emerging approaches, policies, and practices, PI provides training and

tools to communities, policymakers, academics, funders, and coalitions focused on